LPC EVALUATION OF SUPERVISED EXPERIENCE

1 1 LPC EVALUATION OF SUPERVISED EXPERIENCE Duration of supervision: (a) Three (3) years or three-thousand (3000) clock hours of full time, on-the-job EXPERIENCE , which is SUPERVISED by an approved LPC supervisor, shall be completed. (b) For each one-thousand (1000) clock hours of full time, on-the-job EXPERIENCE , three hundred fifty (350) hours shall be direct face to face client contact. (c) "Full time" means at least twenty (20) hours per week. (d) Weekly, face-to-face supervision shall be accrued under an LPC at the ratio of forty-five (45) minutes of supervision for every twenty (20) hours of on-the-job EXPERIENCE .

2 (e) "Group supervision" means an assemblage of counseling supervisees consisting of from two (2) to six (6) members and no more than one-half ( ) of the required supervision hours may be received in group supervision. Name of Supervisee: _____ Current Place of Employment: _____ Name of Supervisor: _____ Name of place of supervision: _____ Address of place of supervision: _____ City, State: _____ Zip: _____ Dates of SUPERVISED EXPERIENCE hours this six-month period: From: _____ To: _____ Total number of SUPERVISED EXPERIENCE hours this six-month EVALUATION period: _____ Total number of direct client contact hours this six-month EVALUATION period: _____ Total number of direct face-to-face supervision hours this six-month EVALUATION period: Individual: _____ Group.

3 _____ Describe the types of clients seen by supervisee at the current setting: _____ _____ Record the approximate percentage of time supervisee spends in the professional activities listed below: Individual counseling: _____ % Group Counseling: _____ % Assessment: _____ % Staffing/Consultation: _____ % Treatment Planning: _____ % Marital, Family, Couples Counseling: _____ % Other: _____ % Total (must equal 100%): _____ % If Other please explain: _____ Licensed Behavioral Practitioners Licensed Marital and Family Therapists Licensed Professional Counselors State Board of Behavioral Health Licensure 3815 N.

4 Santa Fe, Ste. 110 Oklahoma City, OK 73118 Telephone: (405) 522-3696 Fax: (405) 522-3691 Oklahoma State Department of HealH Form 79 Protective Health Services DRAFT (Rev. 10/06) Rate your supervisee in comparison to other professionals with commensurate EXPERIENCE . Place an X under the appropriate skill level. No observation Needs improvement Acceptable Above average skill Individual counseling: Group counseling: Marital, Family, Couples counseling: Child counseling: Assessment/diagnosis: Treatment planning: Makes appropriate referrals: Consults with other professionals: Conducts research: Knows licensing law and rules: Conforms to Rules of Professional Conduct: Uses Disclosure Statement: Is prompt/current on paperwork and records: Cares for own mental health: Utilizes supervision sessions effectively.

5 Maintains professional boundaries: Stays within limits of competence level: Keeps current with professional literature: Other: _____ Dates of observations (live or tape) for this six-month period: _____ and _____ Date(s) of contact with on-site supervisor for this six-month period: _____ Additional Supervisor comments: _____ _____ _____ _____ _____ 3 LPC RECORD OF SUPERVISED EXPERIENCE Candidate s Name (please print): Approved Supervisor s Name (please print): Date Supervision Agreement was approved by the Department: WORK WEEK BEGINNING DATE DATE(S) MET WITH YOUR SUPERVISOR TOTAL # OF FACE-TO-FACE SUPERVISION HOURS GRP INDTOTAL # OF DIRECT CLIENT CONTACT HOURS TOTAL # OF SUPERVISED EXPERIENCE HOURS TOTAL CANDIDATE S SIGNATURE: _____ Date: _____ SUPERVISOR S SIGNATURE: _____ Date: _____